Enclosed please find the Department of Health Care Policy ... Accountable Care...Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 June 28, 2019 The

1570 Grant Street, Denver, CO 80203-1818 P 303.866.2993 F 303.866.4411

www.colorado.gov/hcpf

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Department of Health Care Policy and Financing

1570 Grant Street

Denver, CO 80203

June 28, 2019

The Honorable Dominick Moreno, Chair Joint Budget Committee 200 East 14th Avenue, Third Floor Denver, CO 80203 Dear Senator Moreno: Enclosed please find the Department of Health Care Policy and Financing’s legislative report on the Medicaid Payment Reform and Innovation Pilot Program to the Joint Budget Committee. Section 25.5-5-415 (4)(a)(III), C.R.S. requires the Department to report that the program is being implemented, concerning the program as implemented, including but not limited to an analysis of the data and information concerning the utilization of the payment methodology, including an assessment of how the payment methodology drives provider performance and participation and the impact of the payment methodology on quality measures, health outcomes, cost, provider satisfaction, and patient satisfaction, comparing those outcomes across all patients utilizing existing state department data by April 15, 2017 and each April 15 thereafter. The Department implemented one payment reform initiative under Section 25.5-5-415 C.R.S. This report will provide a brief background on the initiative, describe the payment methodology and quality measures, provide performance data, and discuss how program design impacts clients and providers. If you require further information or have additional questions, please contact the Department’s Legislative Liaison, David DeNovellis, at [email protected] or 303-866-6912. Sincerely,

Kim Bimestefer Executive Director

mailto:[email protected]



KB/maq Enclosure(s): 2019 Medicaid Payment Reform and Innovation Pilot Program Report

Cc: Representative Daneya Esgar, Vice-chair, Joint Budget Committee Representative Chris Hansen, Joint Budget Committee

Representative Kim Ransom, Joint Budget Committee Senator Bob Rankin, Joint Budget Committee

Senator Rachel Zenzinger, Joint Budget Committee John Ziegler, Staff Director, JBC

Eric Kurtz, JBC Analyst Lauren Larson, Director, Office of State Planning and Budgeting Legislative Council Library State Library John Bartholomew, Finance Office Director, HCPF

Laurel Karabatsos, Interim Health Programs Office Director & Medicaid Director, HCPF Tom Massey, Policy, Communications, and Administration Office Director, HCPF

Bonnie Silva, Community Living Office Director, HCPF Chris Underwood, Health Information Office Director, HCPF Stephanie Ziegler, Cost Control and Quality Improvement Office Director, HCPF Rachel Reiter, External Relations Division Director, HCPF David DeNovellis, Legislative Liaison, HCPF



e


1570 Grant Street

Denver, CO 80203

June 28, 2019

The Honorable Rhonda Fields, Chair Health and Human Services Committee 200 E. Colfax Avenue Denver, CO 80203

Dear Senator Fields: Enclosed please find the Department of Health Care Policy and Financing’s legislative report on the Medicaid Payment Reform and Innovation Pilot Program to the Senate Health and Human Services Committee. Section 25.5-5-415 (4)(a)(III), C.R.S. requires the Department to report that the program is being implemented, concerning the program as implemented, including but not limited to an analysis of the data and information concerning the utilization of the payment methodology, including an assessment of how the payment methodology drives provider performance and participation and the impact of the payment methodology on quality measures, health outcomes, cost, provider satisfaction, and patient satisfaction, comparing those outcomes across all patients utilizing existing state department data by April 15, 2017 and each April 15 thereafter. The Department implemented one payment reform initiative under Section 25.5-5-415 C.R.S. This report will provide a brief background on the initiative, describe the payment methodology and quality measures, provide performance data, and discuss how program design impacts clients and providers. If you require further information or have additional questions, please contact the Department’s Legislative Liaison, David DeNovellis, at [email protected] or 303-866-6912. Sincerely,






Cc: Senator Brittany Pettersen, Vice-Chair, Health and Human Services Committee Senator Larry Crowder, Health and Human Services Committee Senator Jim Smallwood, Health and Human Services Committee Senator Faith Winter, Health and Human Services Committee Legislative Council Library State Library John Bartholomew, Finance Office Director, HCPF


Bonnie Silva, Community Living Office Director, HCPF Chris Underwood, Health Information Office Director, HCPF Stephanie Ziegler, Cost Control and Quality Improvement Office Director, HCPF Rachel Reiter, External Relations Division Director, HCPF

David DeNovellis, Legislative Liaison, HCPF



e


1570 Grant Street

Denver, CO 80203

June 28, 2019 The Honorable Susan Lontine, Chair Health and Insurance Committee 200 E. Colfax Avenue Denver, CO 80203 Dear Representative Lontine: Enclosed please find the Department of Health Care Policy and Financing’s legislative report on the Medicaid Payment Reform and Innovation Pilot Program to the Health and Insurance Committee. Section 25.5-5-415 (4)(a)(III), C.R.S. requires the Department to report that the program is being implemented, concerning the program as implemented, including but not limited to an analysis of the data and information concerning the utilization of the payment methodology, including an assessment of how the payment methodology drives provider performance and participation and the impact of the payment methodology on quality measures, health outcomes, cost, provider satisfaction, and patient satisfaction, comparing those outcomes across all patients utilizing existing state department data by April 15, 2017 and each April 15 thereafter. The Department implemented one payment reform initiative under Section 25.5-5-415 C.R.S. This report will provide a brief background on the initiative, describe the payment methodology and quality measures, provide performance data, and discuss how program design impacts clients and providers. If you require further information or have additional questions, please contact the Department’s Legislative Liaison, David DeNovellis, at [email protected] or 303-866-6912. Sincerely,






Cc: Representative Yadira Caraveo, Vice Chair, Health and Insurance Committee Representative Mark Baisley, Health and Insurance Committee Representative Susan Beckman, Health and Insurance Committee Representative Janet P. Buckner, Health and Insurance Committee Representative Dominique Jackson, Health and Insurance Committee Representative Sonya Jaquez Lewis, Health and Insurance Committee Representative Kyle Mullica, Health and Insurance Committee Representative Matt Soper, Health and Insurance Committee Representative Brianna Titone, Health and Insurance Committee Representative Perry Will, Health and Insurance Committee Legislative Council Library State Library John Bartholomew, Finance Office Director, HCPF Laurel Karabatsos, Interim Health Programs Office Director & Medicaid Director, HCPF Tom Massey, Policy, Communications, and Administration Office Director, HCPF Bonnie Silva, Community Living Office Director, HCPF Chris Underwood, Health Information Office Director, HCPF Stephanie Ziegler, Cost Control and Quality Improvement Office Director, HCPF Rachel Reiter, External Relations Division Director, HCPF David DeNovellis, Legislative Liaison, HCPF



e


1570 Grant Street

Denver, CO 80203

June 28, 2019

The Honorable Jonathan Singer, Chair Public Health Care and Human Services Committee 200 E. Colfax Avenue Denver, CO 80203 Dear Representative Singer: Enclosed please find the Department of Health Care Policy and Financing’s legislative report on the Medicaid Payment Reform and Innovation Pilot Program to the House Public Health Care and Human Services Committee. Section 25.5-5-415 (4)(a)(III), C.R.S. requires the Department to report that the program is being implemented, concerning the program as implemented, including but not limited to an analysis of the data and information concerning the utilization of the payment methodology, including an assessment of how the payment methodology drives provider performance and participation and the impact of the payment methodology on quality measures, health outcomes, cost, provider satisfaction, and patient satisfaction, comparing those outcomes across all patients utilizing existing state department data by April 15, 2017 and each April 15 thereafter. The Department implemented one payment reform initiative under Section 25.5-5-415 C.R.S. This report will provide a brief background on the initiative, describe the payment methodology and quality measures, provide performance data, and discuss how program design impacts clients and providers. If you require further information or have additional questions, please contact the Department’s Legislative Liaison, David DeNovellis, at [email protected] or 303-866-6912. Sincerely,






Cc: Representative Dafna Michaelson Jenet, Vice-Chair, Public Health Care and Human Services Committee Representative Yadira Caraveo, Public Health Care and Human Services Committee Representative Lisa Cutter, Public Health Care and Human Services Committee Representative Serena Gonzales-Gutierrez, Public Health Care and Human Services Committee Representative Cathy Kipp, Public Health Care and Human Services Committee Representative Lois Landgraf, Public Health Care and Human Services Committee Representative Colin Larson, Public Health Care and Human Services Committee Representative Larry Liston, Public Health Care and Human Services Committee Representative Kyle Mullica, Public Health Care and Human Services Committee Representative Rod Pelton, Public Health Care and Human Services Committee Legislative Council Library State Library John Bartholomew, Finance Office Director, HCPF


Bonnie Silva, Community Living Office Director, HCPF Chris Underwood, Health Information Office Director, HCPF Stephanie Ziegler, Cost Control and Quality Improvement Office Director, HCPF Rachel Reiter, External Relations Division Director, HCPF

David DeNovellis, Legislative Liaison, HCPF

ACCOUNTABLE CARE COLLABORATIVE PAYMENT REFORM PROGRAM REPORT

Section 25.5-5-415, C.R.S.: Medicaid payment reform and innovation pilot program

Submitted June 30, 2019 to:

Joint Budget Committee

House Health, Insurance, and Environment Committee

Senate Health and Human Services Committee

Department of Health Care Policy & Financing June 30, 2019 Payment Reform Report Page 2

Section 25.5-5-415 (4)(a)(IV), C.R.S. states:

(IV) On or before April 15, 2017, and each April 15 that the program is being implemented,

concerning the program as implemented, including but not limited to an analysis of the

data and information concerning the utilization of the payment methodology, including an

assessment of how the payment methodology drives provider performance and

participation and the impact of the payment methodology on quality measures, health

outcomes, cost, provider satisfaction, and patient satisfaction, comparing those outcomes

across patients utilizing existing state department data. Specifically, the report must

include:

(A) An evaluation of all current payment projects and whether the state department intends

to extend any current payment project into the next fiscal year;

(B) The state department's plans to incorporate any payment project into the larger

Medicaid payment framework;

(C) A description of any payment project proposals received by the state department since

the prior year's report, and whether the state department intends to implement any new

payment projects in the upcoming fiscal year; and

(D) The results of the state department's evaluation of payment projects pursuant to

paragraph (a.5) of this subsection (4).


Executive Summary The Department of Health Care Policy & Financing (Department) is pleased to submit this

annual report on payment reform initiatives required under Section 25.5-5-415, C.R.S.

(also known as House Bill 12-1281). The report provides an update on a payment reform

initiative operated by Rocky Mountain Health Plans (RMHP). The payment reform initiative

called Rocky Mountain Health Plans Prime (RMHP Prime) is run within the Accountable Care

Collaborative (ACC) but has a different payment methodology than the rest of the program.

RMHP Prime started in September 2014 and continued through FY 2017-18.

Enrollment

RMHP operates the Region 1 Regional Care Collaborative Organization as part of the

Department’s ACC. RMHP Prime serves members in six counties: Garfield, Gunnison,

Montrose, Mesa, Pitkin and Rio Blanco. In FY 2017-18, total monthly enrollment in Prime

averaged 36,487 members. RMHP Prime primarily serves adult members, plus a small

number of children with disabilities.

Financial Performance and Payments

The Department pays RMHP Prime a set monthly payment for enrolled members that

covers a comprehensive set of physical health services. Total expenditures for members

enrolled in RMHP Prime in FY 2017-18 were $198,446,756; this was an increase of

$24,288,330. The reasons for the increased costs are listed below.

Amount of Increase Reason for Increase

$10 million Hepatitis C pharmaceutical treatments1

$8 million Enrollment increase

$4.8 million Rate increase of 2.7%

$1.3 million Federally required Health Insurance Provider Fee payment2

RMHP offers primary care medical providers the opportunity to participate in its RMHP

Prime payment reform program where a practice can receive a sub-capitated payment

each month to cover a practice’s services for all the members who are under the practice’s

care. In FY 2017–18, 46 practices participated in RMHP Prime’s payment reform program

1 Pharmaceutical treatments for Hepatitis C were paid directly by the Department for members enrolled in

RMHP Prime. These treatments were not included as a covered service in Prime based on price volatility 2 Section 9010 of the Affordable Care Act (ACA) created the Health Insurance Providers Fee as an excise tax

on all health insurance providers. The Department withholds from the capitation an estimated amount of the

fee that is likely to be attributed to Medicaid revenue. When the fee is actualized, the department reconciles the withhold and adjusts the net rates.


and received sub-capitated payments for an average monthly enrollment of 15,667

attributed members.

In addition to reporting on the overall program costs, this year, for the first year, the

Department and its actuary compared the estimated costs of the population enrolled in

RMHP Prime to estimates of what the population would have cost had they not enrolled in

the program. The results of this analysis showed that RMHP Prime, as it currently operates,

reduces the total cost of care for members by a small margin (less than two percent), or

approximately $3 million, even after accounting for the additional administrative costs and

increased investment in primary care made under RMHP Prime. The analysis indicates

that the program was more successful in generating cost savings among individuals with

disabilities and individuals older than 64 years of age, but experienced cost increases for

Adults without Dependent Children. Of note, the Department used the most recent

available data for the analysis, rather than data limited to the FY 2017-18 evaluation year.

This allows the Department to also utilize the analysis for broader performance

management The Department believes the analysis is still a reasonable representation of

program performance for the FY 2017-18 evaluation period covered by this report as the

operations of RMHP Prime has not changed significantly.

Quality Performance

The Department incorporates quality measurement into its payment model for RMHP Prime

by using four quality measures to adjust RMHP Prime’s medical loss ratio. A medical loss

ratio calculates how much money is spent on providing medical services compared to

administrative services and profit. The more quality measures RMHP Prime meets, the

more money RMHP Prime can allocate for administrative services and profit. For FY 2017–

18, RMHP Prime met its targets in all four quality measures for the program: body mass

index (BMI) assessment for adults; HbA1c poor control (a measure of diabetes control);

screening for clinical depression and follow-up plan; and percentage of practices that

completed a follow-up Patient Activation Measure (PAM®) assessment for members that

had initial low activation scores.

The Department also uses the measures in the table below to compare health and cost

outcomes of RMHP Prime members against a similar population of members enrolled in

the statewide ACC.


FY 2017-18 Performance Comparison

Performance Measure RMHP Prime ACC

Emergency Department Visits 898 visits per

1,000 members

812 visits per

1,000 members

Behavioral Health Penetration Rate 19.7% 19.3%

Hospital All-cause Readmission Rate 9.5% 10.3%

Members with 1+ visit to Primary Care Medical

Provider 69.2% 62.7%

Provider Support and Member Experience

RMHP leverages its Accountable Care Collaborative Region 1 Practice Transformation Team

to support practices in building capacity and better serving members. Such practice support

builds strong relationships with providers and helps practices make the best use of its staff

and resources for member care. RMHP offers practice transformation to all practices but

there has been uneven uptake of these opportunities depending on the readiness and

ability of individual practices to integrate new approaches.

To better serve members, RMHP seeks member feedback in several different ways. First,

through the Voice of the Consumer project RMHP uses in-depth focus groups to assess

and to respond to member experience. Second, RMHP uses a Member Experience and

Advisory Committee to improve care and understand the needs of members. Finally, a

CAHPS® (Consumer Assessment of Healthcare Providers and Systems) survey is used to

get feedback on RMHP Prime member experience. The CAHPS® results reported that 68.7

percent of respondents rated their provider favorably (a 9 or 10 on a 1-to-10 scale) and

56.5 percent rated RMHP Prime favorably. In addition, 92.2 percent of members were

pleased with how their providers communicated with them.

Evaluation

This year, with the comparison of the estimated costs of the population enrolled in RMHP

Prime to estimates of what the population would have cost had they not enrolled in the

program, the Department is better able to evaluate RMHP Prime. The Department’s

conclusion is that RMHP Prime is delivering similar performance to the statewide ACC, while

providing some cost savings with higher rates of member experience and utilization of

primary care. These indicate the value of continuing to operate RMHP Prime at the same


time as the Department pursues further performance improvements, such as emergency

department utilization.

Without clear indication of substantial cost savings or improvement in quality, the

Department does not see a reason at this time to expand RMHP Prime beyond its current

scope. Additionally, the Department is not confident the model could be easily replicated

as RMHP has played a unique role in the region for decades as a commercial health

insurance plan and as a Department contractor for Child Health Plan Plus and Medicaid.

That said, the Department will work with RMHP to leverage its work around primary care

utilization and provider communications to strengthen these efforts within the broader

ACC.

Looking Ahead

As part of the recent procurement of new vendors for the next iteration of the Accountable

Care Collaborative, the Department is continuing RMHP Prime in Region 1 under the

authority of C.R.S. Section 25.5-5-415. The new contract began on July 1, 2018.

The second phase of the Accountable Care Collaborative builds off the best practices

learned from all Department programs, including RMHP Prime. The core innovation for

Phase II has been joining the administration of physical and behavioral health under one

regional entity, the Regional Accountable Entity (RAE). This combined administration is

designed to promote the population’s health and functioning, improve coordination of care,

and improve the member experience by reducing system fragmentation and creating one

point of accountability.

The Department also added new cost savings requirements for Phase II of the Accountable

Care Collaborative contracts, which include:

• Return on program investment for the RAEs of between 1.5-2.0 to 1 during the first

year of operations, with the return on investment increasing in subsequent years.

• Savings target of two percent (2%) or more below the fee-for-service equivalent

for RMHP Prime.

For the Phase II contracts, the Department also incorporated the RMHP Prime quality-

based medical loss ratio adjustments into the limited managed care capitation initiative

being operated in Region 5 with Colorado Access and Denver Health Medicaid Choice.

Additionally, the Department modified the Accountable Care Collaborative payments so the

RAEs have the opportunity to create flexible, value-based administrative payments to best

meet the needs and goals of their contracted Primary Care Medical Providers. This latter

arrangement follows some of the lessons learned from the RMHP Prime payment reform

program and other Department initiatives.


Introduction

The Department of Health Care Policy & Financing (Department) is pleased to submit this

annual report on payment reform initiatives under Section 25.5-5-415, C.R.S. (also known

as House Bill 12-1281). The report provides an update for the program underway as a

result of this legislation.

Rocky Mountain Health Plans Prime (RMHP Prime) was run within the Accountable Care

Collaborative (ACC) but has a different payment methodology than the rest of the program.

RMHP Prime started in September 2014 and continued through FY 2017–18.

Enrollment

Rocky Mountain Health Plans (RMHP) operated the Region 1 Regional Care Collaborative

Organization as part of the ACC from 2011 through FY 2017-18. In September 2014, RMHP

implemented RMHP Prime to serve members in six counties in Region 1: Garfield,

Gunnison, Montrose, Mesa, Pitkin and Rio Blanco. The majority of RMHP Prime members

are adults. The only children enrolled in RMHP Prime are those with disabilities.

Eligible members are automatically enrolled in the program on an ongoing basis. Members

who do not wish to participate have 30 days to opt out prior to their enrollment date, and

an additional 90 days to opt out after enrollment. In FY 2017–18, monthly enrollment in

Prime averaged 36,487 members, an increase from the monthly average of 34,892 the

previous year.

Program Performance

Financial Performance and Payment Methodology

In FY 2017–18, total expenditures for members enrolled in the RMHP Prime program

equaled $198,446,756. This was an increase of $24,288,330 million from the previous

year’s expenditures of $174,158,426. The reasons for the increased costs are listed in

Table 1.


Table 1. Detail of RMHP Prime Cost Increases for FY 2017-18

Amount of Increase Reason for Increase

$10 million Hepatitis C pharmaceutical treatments3

$8 million Enrollment increase

$4.8 million Rate increase of 2.7%

$1.3 million Federally required Health Insurance Provider Fee payment4

The Department pays RMHP Prime a set monthly fee in exchange for covering a

comprehensive set of physical health services to its participating members. This is full risk

capitation.

RMHP Prime, in turn, offers primary care medical providers (PCMPs) the opportunity to

participate in a payment reform program. The 46 participating PCMPS receive a single sub-

capitation payment each month to cover the cost of all the practice’s services for the

members who are under the practice’s care. This payment is calculated based on the

number of participating members who are attributed to the practice. Payments to each

practice are risk-adjusted, so the practices are not incentivized to take only well members

and exclude sicker or older members. An average of 15,667 members monthly were

attributed to 46 practices participating in the RMHP Prime payment reform program during

FY 2017-18.

Under RMHP Prime’s payment reform program, PCMP practices have both upside and

downside financial risk. If a PCMP practice’s actual costs exceed the sub-capitation

payment, RMHP Prime takes back 5 percent of the practice’s payment for that month.

However, if a PCMP practice’s expenditures were lower than expected and the practice met

relevant quality targets, RMHP Prime will share savings at the end of the year. Savings are

also shared with community mental health centers in the region that meet contractual

requirements to work with the RMHP health engagement team and to support the

coordination of physical and behavioral health care. This dual emphasis on cost and quality

increases provider accountability for both fiscal outcomes and care delivery outcomes.

3 Pharmaceutical treatments for Hepatitis C were paid directly by the Department for members enrolled in

RMHP Prime. These treatments were not included as a covered service in Prime based on price volatility 4 Section 9010 of the Affordable Care Act (ACA) created the Health Insurance Providers Fee as an excise tax

on all health insurance providers. The Department withholds from the capitation an estimated amount of the

fee that is likely to be attributed to Medicaid revenue. When the fee is actualized, the department reconciles the withhold and adjusts the net rates.


In addition to reporting on the overall program costs, this year, for the first time, the

Department and its actuary compared the estimated costs of the population enrolled in

RMHP Prime to estimates of what the population would have cost had they not enrolled in

the program. The results of this analysis showed that RMHP Prime, as it currently operates,

reduces total cost of care for members by a small margin. This savings remains even after

accounting for the increased administrative costs and investments in primary care made

under RMHP Prime. Reductions in higher cost services, such as hospitalizations, and

limiting the exacerbation of conditions requiring more frequent utilization of lower cost

services drive the offset that results in aggregate programmatic savings. The analysis also

indicates that the program was more successful in generating cost savings among

individuals with disabilities and individuals older than 64 years of age, but experienced cost

increases for Adults without Dependent Children.

It is worth noting that there are inherent challenges in estimating what members would

have cost had they not enrolled in the program. For example, to draw a meaningful

conclusion from this type of analysis, it is important to find an appropriately comparable

population to use as a proxy for the enrolled population and to account for regional

differences in provider reimbursement rates. The Department’s actuary used a population

from Pueblo County, and risk adjusted (a process of adjusting expected expenditures for

individuals based on their health status as indicated by historical claims data) the

population to be comparable to the health status of those enrolled in RMHP Prime. The

actuary also adjusted the price of services provided in Pueblo to be comparable to the price

of services in the RMHP Prime region. A multitude of additional adjustments such as these

are applied to the data to get to a reasonable approximation of costs had the members

never been enrolled in RMHP Prime.

The Department would also note that the most recent available data was used for the

analysis, rather than data limited to the FY 2017-18 evaluation year. This will allow the

Department to utilize the analysis for broader performance management in addition to the

insight provided for this report. While the timeframe is not aligned with the evaluation

period of the report, the Department believes that because the underlying program has

not changed significantly, the analysis is still a reasonable representation of RMHP Prime

performance for the FY 2017-18 evaluation period covered by this report.


Medical Loss Ratio Metrics

Quality measures help the Department and RMHP monitor how well the RMHP Prime

program is meeting the health needs of the population it serves. The Department has also

incorporated quality measures into the RMHP Prime payment model by adjusting RMHP

Prime’s medical loss ratio based on the program’s performance on four measures. A

medical loss ratio calculates how much money is spent on providing medical services

compared to administrative services and profit. The more quality measures RMHP Prime

meets, the greater proportion of their payment they can allocate for administrative services

and profit.

RMHP Prime’s four measures align with quality measures used in other initiatives

throughout the state and have established data sources. Three of the four FY 2017–18

quality measures for RMHP Prime are similar to the measures used in the previous years

of the program:

• Body mass index (BMI) assessment for adults

• HbA1c poor control (a measure of diabetes control)

• Follow-up utilization of the Patient Activation Measure (PAM®)

The one change in measures was made in response to changing treatment practices among

providers. The Department replaced the previous measure of antidepressant medication

management for acute and continuation phases with the new measure of screening for

clinical depression and follow-up plan. This new measure aligns with the State Innovation

Model quality measures.

RMHP Prime met the benchmarks in all four measures.


Table 2. Quality Measures and Performance Targets for RMHP Prime Quality Measure Target(s) FY 2017–18 Performance

Adult Body Mass Index

(BMI) Assessment (HEDIS)

• Assessment completed for at

least 93.5% of members

• 97.5% of adults were

assessed

HbA1c Poor Control

(>9.0%) (HEDIS)

• No more than 29.2% of

members have an HbA1c

above 9.0%

• 27.9% of members had

HbA1c above 9.0%

Screening for Clinical

Depression and Follow Up

Plan

• 55.6% of members 12 years

and older were screened for clinical depression on the date

of the encounter AND, if

positive, a follow-up was

documented

• 64.9% of eligible members

were screened for clinical depression and had follow-up

documented if the screen was

positive

Patient Activation Measure

(PAM®)

• For practices actively using

the PAM® tool, at least 30%

of attributed members who had an initial PAM® level of 1

or 2 completed a follow up PAM® by the end of June

2018.

• 43.9% of members that had

an initial PAM® level of 1 or 2

completed a follow up PAM®

by the end of June 2018.

Health Effectiveness Data and Information Set (HEDIS) Measures for RMHP Prime

The first two quality measures are from HEDIS (Health Effectiveness Data and Information

Set). These measures were developed by the National Committee for Quality Assurance

and are used widely in managed care. The two measures were chosen to measure

approximate practice proficiency in several areas:

• BMI assessment measures preventive care

• HbA1c control measures how well chronic conditions are managed

RMHP Prime met the benchmarks for these two HEDIS measures.

Screening for Clinical Depression and Follow Up Plan for RMHP Prime

For FY 2017–18, RMHP Prime was assessed on the percent of members 12 years and older

that were screened for clinical depression using an age appropriate standardized

depression screening tool and, if positive, a follow-up was documented. Screening

members for depression and establishing follow-up plans for those who report indicators

of depression is an important step toward integrating physical health and behavioral health

in primary care settings. This measure is a National Quality Forum measure that is being

used for Colorado’s State Innovation Model (SIM).


Performance on this measure was calculated based on data reported to the University of

Colorado Health Systems’ tool called SPLIT that is being used for SIM. RMHP Prime

exceeded the 55.6 percent benchmark for FY 2017-18 and achieved a rate of 64.9 percent.

RMHP Prime’s Use of the Patient Activation Measure®

The Patient Activation Measure (PAM®) is a tool used to assess a member’s level of

engagement in their health care. Members complete a short survey and are rated at a

Level 1 through 4, with 4 being the most activated or engaged in their care. The PAM® is

an important tool that providers can use to match interventions and education with a

member’s level of health knowledge and readiness to change. The survey can also be used

to help providers predict patterns of health and resource utilization.

Given that the PAM® is a new tool to most providers, RMHP has elected to implement the

tool in stages. During the first two contract periods, RMHP Prime focused on getting

practices to implement the basic features of the tool within their clinical workflows. During

the third contract period, RMHP Prime focused on getting practices to use the Coaching

for Activation portion of the tool. Over this year, RMHP Prime worked with these practices

to use the Coaching for Activation portion of the PAM® to identify and work with members

who had low levels of activation. During FY 2017-18, 43.9% of members who were rated

at a low level of activation received the Coaching for Activation portion of the PAM® and

completed a follow-up PAM®, exceeding the benchmark of 30%.

Quality Metrics

The Department also uses additional measures to compare health and cost outcomes of

RMHP Prime members against a similar population of members enrolled in the statewide

ACC. For a comparison population within the Accountable Care Collaborative, the

Department reviewed all members not enrolled in a managed care organization (e.g. RMHP

Prime or Denver Health Medicaid Choice) who were either an adult or a child with

disabilities. Note, these rates are not risk adjusted. Additional details on each of the

measures can be found in the narrative following table 3.


Table 3. FY 2017-18 Performance Comparison of RMHP Prime and the Statewide

Accountable Care Collaborative

Performance Measure RMHP Prime ACC

Emergency Department Visits 898 visits per

1,000 members

812 visits per

1,000 members

Behavioral Health Penetration Rate 19.7% 19.3%

Hospital All-cause Readmission Rate 9.5% 10.3%

Members with 1+ visit to Primary Care

Medical Provider

69.2% 62.7%

Emergency Department Use Among RMHP Prime Members

The Department looks at emergency department use to understand how well the program

is managing the health needs of its members, preventing high-cost services, and shifting

utilization to preventative care settings, like primary care. The emergency department

measure tracks the number of emergency room visits on the same date of service for the

same member that did not result in an inpatient admission, per thousand members.

Members of RMHP Prime visited the emergency department at a rate of 898 visits per

thousand members during FY 2017-18, which is basically unchanged from last year’s rate

of 895 visits per thousand members. For FY 2017-18, the RMHP Prime rate is higher than

the average across the same population of members in the ACC (812 visits per thousand

members) and the same population of members in the ACC Region 1 administered by

RMHP (723 visits per thousand members).

RMHP uses several approaches for preventing unnecessary use of the emergency

department. One approach is improved coordination of behavioral health care with primary

care, allowing RMHP Prime to connect more people with needed behavioral health services

before they have an emergency situation. RMHP also uses practice transformation to

increase the capacity of primary care practices to meet the needs of members with complex

conditions.

Another strategy RMHP uses is the Health Engagement Team Program. This program

provides care management for members with a history of high emergency department

utilization. All ACC members in Region 1, including RMHP Prime members, have access to

this program, which is a pilot partnership between RMHP, two mental health organizations


and 12 primary care practices on the Western Slope. This program embeds community

health workers in primary care practices to coordinate care and connect members with

needed medical care, behavioral health and social services.

Access to Behavioral Health Services for RMHP Prime Members

One of the goals of RMHP Prime is to improve access to needed behavioral health services

and better integrate those services with medical care. By ensuring that members get the

behavioral health services they need, the Department can avoid costly crisis care and

emergency department visits. In addition, addressing behavioral health can often improve

treatment outcomes of chronic diseases, since these often occur together.

One way to measure access to behavioral health services is the behavioral health

penetration rate. This rate explains what percentage of the population served by a health

plan actually receives behavioral health services. In FY 2017–18, the behavioral health

penetration rate for RMHP Prime members decreased to 19.7 percent from nearly 22

percent in FY 2016–17. This rate was slightly higher than the 19.3 rate for ACC members

who received behavioral services through the behavioral health organizations.

RMHP works on several different levels to improve access to behavioral health care. RMHP

has made behavioral health integration a key component of its practice transformation

efforts. RMHP’s practice transformation program has added a Ph.D.-level clinical

psychologist to coach practices on successfully integrating behavioral health services into

their workflow. Additionally, RMHP uses another program called Colorado is Expanding

Access to Rural Team-based Healthcare (CO–EARTH) to help small rural practices address

behavioral health needs.

Finally, RMHP Prime maintains strong partnerships with behavioral health providers and

others in the community who can connect members to behavioral health services. An

integrated executive committee provides strategic and operational oversight of the

program. This committee includes two key community mental health centers within RMHP

Prime’s counties. The committee meets quarterly and works to develop and advance

shared principles of an integrated delivery system.

Hospital All-cause Readmission Rate for RMHP Prime Members

As the Department continues to expand its cost-containment efforts, it has begun adding

new measures to monitor the health of its programs. Unnecessary readmissions to a

hospital can be costly and be an indicator of low-quality care and/or poor care coordination

following the initial hospital discharge. It has become standard practice to monitor hospital


readmissions, particularly for health plans and accountable care organizations. To

incentivize reductions in inappropriate hospitalizations, the Centers for Medicare and

Medicaid Services expanded accountability for avoidable readmissions throughout its

quality reporting and payment programs.

The Department has chosen to measure all readmissions to a hospital for any cause within

30 days of hospital discharge, with the exception of the following conditions: pregnancy;

perinatal conditions; chemotherapy; rehabilitation; organ transplants; and planned

procedures. RMHP Prime had a readmission rate of 9.5 percent, which was better than the

10.3 percent average readmission rate for the ACC.

Members with at Least 1 Visit to PCMP for RMHP Prime Members

The goals of the initial phase of the Accountable Care Collaborative were to ensure member

access to comprehensive primary care and to a focal point of care, referred to as a Primary

Care Medical Provider. Promoting utilization of a Primary Care Medical Provider supports

preventive and well-care and is expected to reduce preventable specialty care, emergency

department visits, and hospital admissions and readmissions.

One way the Department can assess whether members have access to and are utilizing

comprehensive primary care is to calculate how many members who were enrolled for 12

continuous months received services from a Primary Care Medical Provider during that time

period. For FY 2017-18, 69.2 percent of RMHP Prime members had at least one visit with

a Primary Care Medical Provider. The RMHP Prime rate is higher than the average statewide

ACC rate of 62.7 percent.

Provider Support

RMHP supports and works with its providers to help them adapt to the evolving health care

landscape and meet the challenges of payment and delivery reform. By supporting

providers, RMHP gives providers the skills and support to work with other providers as part

of a connected health neighborhood.

The Practice Transformation Team at RMHP fosters quality improvement in the delivery of

team-based, patient-centered primary care. A multi-disciplinary team of Quality

Improvement Advisors, Clinical Informaticists, and a Ph.D.-level Behavioral Health Advisor

provide on-site coaching, training, and provision of resources. To support the unique needs

of rural practices, RMHP offers specific practice transformation opportunities like CO-

EARTH to develop skills and build infrastructure. The Practice Transformation Team also


creates learning collaboratives to help practices integrate what they are learning from other

initiatives such as Comprehensive Primary Care Initiative (CPCi), Comprehensive Primary

Care Plus (CPC+), Transforming Clinical Practice Initiative (TCPI) and the Colorado State

Innovation Model (SIM).

The RMHP Practice Transformation Program offers clinical guidelines and patient resources

for specific medical conditions like diabetes, high blood pressure and depression. It also

offers extensive learning opportunities about topics such as motivational interviewing,

patient self-management and activation, quality improvement, care coordination across

the health neighborhood, and data use to track needs and outcomes. Some examples of

training include:

• Bridges Out of Poverty. Based in part on Dr. Ruby K. Payne’s myth-shattering A

Framework for Understanding Poverty, Bridges reaches out to millions of service

providers and businesses whose daily work connects them with people in poverty.

• Disability Competent Care Training. These trainings on disability-competent care are

facilitated by the Colorado Cross-Disability Coalition (CCDC), using a case study

model. Trainings are offered in person and by webinar. In addition, a pediatric-

focused training is offered to pediatric providers.

RMHP Prime uses practice transformation, care coordination and flexible financial

payments to engage providers in meaningful operational and cultural change. During FY

2017-18, some of the most significant advances for RMHP Prime practices occurred around

growing the workforce and expanding access to behavioral health services. For example,

three separate practices were able to hire their first behavioral health practitioner based

on the multiple lines of support from RMHP Prime.

Member Experience

Member engagement is an important part of RMHP Prime’s strategy. As described above,

the program uses the Patient Activation Measure (PAM®) to assess the level of a member’s

engagement in their care. RMHP Prime uses care coordinators and care managers to help

members with low activation scores to overcome barriers and do their part to stay healthy.

Care Coordination to Improve Member Experience

Care coordination continues to be a key strategy for improving the experience of members,

particularly those with complex medical conditions or those requiring social services.

RMHP’s philosophy is that care coordinators should be located as close to the practice site

as possible. Some practices have in-practice care coordination services, while others rely


on the staff of RMHP regional care coordinators that serve all of Region 1’s ACC members,

including RMHP Prime members.

RMHP uses community health workers to help members remain knowledgeable about their

health and engaged in their care. The Health Engagement Team Project, embeds

behavioral health-trained community health workers in some of its primary care sites. This

workforce supports RMHP members who need extra support in maintaining their self-care

and addressing social and behavioral factors that affect members’ health. Community

health workers screen for behavioral health needs, offer health education and coach

members on taking care of their health. They also work specifically with RMHP Prime

members who have had four or more emergency department visits in the past 12 months,

offering intensive care coordination with behavioral approaches such as shared care

planning and motivational interviewing.

Below are some examples of how RMHP Prime’s approach to care coordination has made

a difference for members:

• Following a car accident that left a man unable to walk or work, a community health

outreach coordinator helped the man apply for social security disability benefits and

find suitable housing for him, his youngest children, and his Great Dane. The

community health outreach coordinator also coordinated ongoing health

appointments for the man and helped him get medical equipment and the food and

housing benefits he needs as he continues his recovery.

• A nurse care coordinator visits a woman at her home weekly to help her manage

her health and complex medication regimen designed to treat a combination of

illnesses, including arthritis, fibromyalgia, chronic obstructive pulmonary disease,

and Meniere's disease. Following multiple falls and a stroke that impaired the

woman’s ability to speak clearly, she requested a care coordinator. The nurse care

coordinator accompanies the woman to her health care visits, helps the woman

communicate her needs and concerns to her providers, clearly documents the

woman’s care plan, and organizes her medications so she takes them correctly. The

nurse care coordinator has been able to improve communication between the

woman and her doctor and has supported the woman’s adherence to her

medications so that the doctor has been able to reduce the number of medications

by about half. The care coordinator has also helped arrange physical and

occupational therapy help at the woman’s home to reduce the likelihood of falls.


Member Feedback

RMHP Prime solicits feedback on member experience of care through a CAHPS® survey

(Consumer Assessment of Healthcare Providers and Systems). The results of the CAHPS®

survey for FY 2017–18 showed that 68.7 percent of respondents rated their provider

favorably, and 56.5 percent rated RMHP Prime favorably. These results align with 2018

national CAHPS® survey results for adult Medicaid populations5. The favorable rating for

RMHP Prime providers increased from 56 percent in FY 2016-17. In addition, for FY 2017-

18, 82.5 percent of respondents reported receiving the care they needed, and 85.8 percent

reported receiving that care in a timely and expedient way. 92.2 percent of respondents

reported being pleased with how their providers communicated with them. This last

measure is nearly twenty percentage points higher than the 2018 national average of 74

percent for adult Medicaid respondents.

RMHP uses in-depth focus groups to assess and to respond to member experience with

the Voice of the Consumer project. RMHP listens to the experiences of members and uses

this knowledge to design a coordinated delivery system that seamlessly links members to

both health services and community resources that address social determinants of health.

Within its counties, RMHP Prime has developed strong partnerships with over 20 providers

and community-based agencies to conduct this work. Not only do these partnerships serve

as a focal point for local clinical and community leadership, they help build consensus

within communities to create and evaluate member-driven system changes.

RMHP also uses a Member Experience and Advisory Committee to improve care and

understand the needs of members. The Committee has focused on understanding the

experiences of members who live with sensory impairments such as deafness, and helping

providers adopt best practices to serve and care for this population. As a result of this

work, RMHP has partnered with The Center for Independence (CFI) to provide sign

language interpreting services for the those who are deaf in Mesa County and the

surrounding area. Interpretive services are provided primarily to the health care provider

community; however, the interpreter fulfills other community interpretive needs as time

allows. The majority of respondents to a 2018 satisfaction survey regarding CFI’s

interpreting reported greater access to communication and improved quality of

interpreting.

5 2018 Chartbook: What Consumers Say About Their Experiences with Their Health Plans and Medical Care.

Agency for Healthcare Research and Quality, 2018 CAHPS Health Plan Survey Database. https://cahpsdatabase.ahrq.gov/files/2018CAHPSHealthPlanChartbook.pdf


Challenges

RMHP Prime includes a group of diverse practices across a vast geographic area. The

practices differ widely in the challenges they face, the resources they have, and their

readiness to adopt and participate in innovative financial and practice transformation

activities. While practice transformation, flexible payments and coordination resources are

offered to all practices, the uptake of these resources varies by practice capacity and

readiness. As a result, improvements in health and cost outcomes may vary across the

program. In this and future pilots, the Department will need to work with its programs to

develop and implement policies and operations that support the broad range of practices

and ensure that both operational and financial interventions are customized to help

practices fine-tune their care models and better serve their members.

Department Assessment

This year the Department is better able to evaluate RMHP Prime utilizing the comparison

of the estimated costs of the population enrolled in RMHP Prime to estimates of what the

population would have cost had they not enrolled in the program. With this analysis, and

the quality and outcome measures presented in this report, the Department has

determined that RMHP Prime is delivering similar performance to the statewide

Accountable Care Collaborative. It did perform better on the number of enrolled members

that had at least one visit with a Primary Care Medical Provider during the reporting period,

showing positive promotion of a medical home model of care. In addition, the 92.2 percent

of members who responded to the CAHPS® who reported being pleased with their how

their providers communicated with them is higher than the 74 percent national average of

adult Medicaid respondents.

However, in contrast, RMHP Prime’s emergency department utilization remained high for

a second year in a row with little change. The Department will work with RMHP Prime to

understand what might be contributing to this level of emergency department utilization

and how they might better be able to lower utilization in the future.

The Department’s conclusion is that RMHP Prime is delivering similar performance to the

statewide ACC, while providing some cost savings and improving member experience with

primary care and utilization of primary care. These indicate the value of continuing to

operate RMHP Prime and to identify further areas to push on performance, particularly

emergency department utilizations.


Without clear indication of significant cost savings or improvement in quality, the

Department does not see a reason at this time to expand RMHP Prime beyond its current

scope. Additionally, the Department is not confident the model could be easily replicated

as RMHP has played a unique role in the region for decades as a commercial health

insurance plan and as a Department contractor for Child Health Plan Plus and Medicaid.

That said, the Department will work with RMHP to leverage its work around primary care

utilization and provider communications to strengthen these efforts within the broader

ACC.

Looking Ahead

As part of the recent procurement of new vendors for the next iteration of the ACC, the

Department is continuing to operate RMHP Prime in Region 1 under the authority of C.R.S.

Section 25.5-5-415. The new ACC contracts began on July 1, 2018.

Accountable Care Collaborative Phase II

The core innovation for the ACC has been joining the administration of physical and

behavioral health under one regional entity, the Regional Accountable Entity. This

combined administration is designed to promote the population’s health and functioning,

improve coordination of care, and improve the member experience by reducing system

fragmentation and creating one point of accountability.

The second phase of the ACC incorporates many lessons learned from the Department’s

programs, including from RMHP Prime.

• Payment flexibility is critical for provider and system success. In Phase II of the

Accountable Care Collaborative, the Regional Accountable Entities are responsible

for creating flexible, value-based administrative payments that best meet the needs

and goals of their contracted Primary Care Medical Providers to fund coordinated,

comprehensive models of care. The Department will work with its Regional

Accountable Entities to develop and implement models that support the broad range

of providers and allow them to better serve their members. The Department is

utilizing lessons learned from RMHP Prime’s payment reform program and other

Department initiatives to guide these activities.

• Use of Quality Measures to Determine Medical Loss Ratio. The use of quality

measures to determine how much money RMHP must spend on providing medical

services compared to administrative services and profit has been a powerful vehicle

to incorporate value-based payment into a traditional managed care payment


arrangement. The Department has incorporated this same approach into the Denver

Health Medicaid Choice contract. By aligning quality measures between the two

physical health managed care programs, the Department will be better able to

compare performance.

New cost savings requirements for Phase II of the ACC include:

• Return on program investment for the RAEs of between 1.5-2.0 to 1 during the first

year of operations, with the return on investment increasing in subsequent years.

• Savings target of two percent (2%) or more below the fee-for-service equivalent

for RMHP Prime.

Alternative Payment Models

The Department is transforming payment design within the rest of the ACC with the goal

of rewarding improved quality of care while containing costs. One way the Department is

doing this is to use differential payment structures to change the way it pays providers.

There are two different payment reform models. Under the Primary Care Alternative

Payment Model (APM), Primary Care Medical Providers can earn higher reimbursement

when designated as meeting specific criteria or performing on quality metrics. To be eligible

to participate in the APM, Primary Care Medical Providers must have more than $30,000 in

annual billing associated with the code set designed for the APM. Primary Care Medical

Providers who fall below this threshold will be excluded from the APM and will not see a

change in their rates. Primary Care Medical Providers who are eligible but choose not to

participate will see a decrease in their rates. This allows the program to make a sustainable

investment into primary care while rewarding performance and increasing provider

accountability.

Federally Qualified Health Centers (FQHCs) will be eligible for two new value-based

payments: value based encounter payments and prospective per-member per-month

payments. The value-based encounter payments will tie four percent of payments to

quality and is similar to the model used for the APM. The Department is also pursuing a

limited pilot payment model for per-member per-month payments to FQHCs.

Cost Control and Quality Improvement Office

The Department created a Cost Control and Quality Improvement Office on July 1, 2018,

established by Senate Bill 18-266 with unanimous support. This office will lead the strategic

development of a targeted, consistent, and comprehensive cost control approach across

all programs, including the ACC and payment reform initiatives such as RMHP Prime.

Initiatives for FY 2018-19 are focused on: pharmacy; home health (including prior

authorization requirements); hospital costs; identifying and reducing “potentially avoidable


costs”; better informing Regional Accountable Entities of high cost, vulnerable members

for increased care coordination and management; instituting analytics that help stratify the

population in order to improve care coordination; and reducing fraud, waste and abuse

including new medical claim system technology to prevent overpayments. Details are

available in the Department’s report released on November 1, 2018. As part of this work,

there is a specific ACC Cost Collaborative in which the Department and Regional

Accountable Entities work together to find opportunities for cost containment and institute

cost control best-practices.

Documents

Enclosed please find the Department of Health Care Policy ... Accountable Care...Department of Health Care Policy and Financing 1570 Grant Street Denver, CO 80203 June 28, 2019 The